Tinnitus Management Strategies

Several studies have looked at the psychological profile of tinnitus patients, and they find that people with debilitating symptoms often have underlying depression and anxiety that make them more susceptible to perseverating on a tinnitus symptom. Meaning, they have a hard time directing their attention away from the signal that they perceive. Additionally, a study that was performed in 2017 found that more than half of the patients in the study had some form of psychological injury such as PTSD symptoms, depression, anxiety, or obsessive-compulsive disorder. If we look at the statistics, there are millions of people that report the experience of tinnitus, but not all of them feel that the symptom is unmanageable.

When the impact on their life is significantly bothersome. Patients who experience tinnitus but don't feel it's bothersome have completed a cycle called habituation. Those that are bothered by their tinnitus have failed to habituate. What does that mean? Habituation is when your brain, through repeated exposure to the same stimulus, starts to suppress its reaction to the stimulus. Basically, you tune it out. When patients come to see me, [many] were told by a physician to just learn to live with the tinnitus. Honestly, that is not wrong because what they're saying is that you need to go through the process of habituation.

Every day, we habituate to different stimuli. If you think of your skin as a sensory receptor, your skin is receptive to pressure and temperature. When you get out of bed in the morning and your body notices that the air temperature is cooler than under the covers, it reacts to that initially and sends a signal to your brain that you might be chilly, but after a while, you warm up and you don't think about the temperature anymore. When you change your clothes in the morning and it goes from a different pressure because the fabric or the fit is different, your skin is receiving that signal telling the brain, but after a few minutes, you're probably not thinking about the socks that you put on, and that's the process of habituation.

The brain will react to it initially, notice the difference, but over time, the sensory receptors will go dormant or it will tune out that neural noise. It doesn't mean that the receptors are not on, it's just the brain is not consciously attending to their signal because it's got another task. The brain can only really focus on a few things at a time, but it's receiving millions of different signals at any given moment.

It has to be able to tune out things that are not going to influence you in a negative way. If the signal it receives is pretty benign, then it's not going to give you a sense of urgency about it. For some reason, we have seen that tinnitus does not get that type of reaction from the brain.

For whatever reason, the brain isn't sensing that the tinnitus is being created by itself. It always assumes your tinnitus is coming from an outside source and it's unable to identify the source. In that instance, it goes into more of a fear reaction because it's not locatable, it can't be identified. Therefore, it has to be monitored as potentially threatening.

Our limbic system guides our fight or flight response. There is a psychological concept that somehow the tinnitus, because it is perceived as negative, is triggering a cycle of fight or flight because we can't control it, we can't locate it or identify it to determine if it is threatening, and so it draws a lot of our cognitive resources to monitor it. Why would this be important? It's important because the focus of tinnitus management is to guide the patient through the habituation process, but also to neutralize the thoughts and emotions that are assigned to the experience of the tinnitus. We need to remove the limbic system's connection and involvement in the experience of the sound, and that requires counseling. The most effective method of tinnitus management is actually a counseling approach known as cognitive behavioral therapy. And that forms the basis of the tinnitus approaches that an audiologist would be applying.

There are suggestions that maybe cognitive behavioral therapy is not the sole approach, and others have been suggested, such as acceptance and commitment therapy. That is essentially because tinnitus, even with counseling and additional supplementation of sound therapy, some will not be able to remove the tinnitus. The tinnitus may become a permanent experience, but that means that we must accept something that we're unable to change. If there is something that we are able to change, such as our reaction, then we need to create a plan and commit to making changes since that is the basis of the acceptance and commitment therapy.

Just as there is no one size fits all for every patient, there are multiple approaches, including mindfulness, essentially just being aware of how the tinnitus makes you feel. Some people will internalize negative thoughts about their tinnitus, but it may not be truly the tinnitus influencing their experience. Let's say you're doing a task and the task is very boring. During that task, you start to listen to your tinnitus because you're not mentally engaged. The task is not giving you enough stimulation. It wasn't that your tinnitus became suddenly very loud, it's just you didn't have enough to keep your attention engaged to the task. At that point, you could recognize the task, maybe I need to do something else. This is no longer appealing, or perhaps the task that you're doing is very difficult and you've been working at it and now you're frustrated and your level of stress has increased, and that draws your attention to your tinnitus because of your level of irritation. Your tinnitus was there the whole time, but you didn't use your attentional resources to listen to it until you started to get overwhelmed.

At that time, mindfully, you would say, "It's the task. I need to take a break. I need to relax and do something else." So, the tinnitus was present, but it wasn't the source of the discomfort, which is what is easily confused for many patients. We have to focus on the things that we do have some measure of control over, and that is the habituation process. Because keep in mind, about 80 to 90 percent of people who experience tinnitus naturally habituate to it. About only 10 to 20 percent of people that experience tinnitus will consider it debilitating and seek treatment. So you can habituate to your tinnitus with counseling alone.

If you visit an audiologist, the approach is based on cognitive behavioral therapy, but we have adapted it for an audiological approach. You may be offered tinnitus retraining therapy, tinnitus activities, treatment or progressive tinnitus management, which are the three most popular management strategies that an audiologist would have access to. Tinnitus retraining therapy has been around the longest and is very much the basis of most approaches, but ultimately the goal is habituation.

Whichever approach is in use, the ultimate goal will be to help you move through reducing your attentional resources to listen to your tinnitus and ideally help you distract yourself away from it and relax yourself at the same time. Distraction and relaxation are primary components of tinnitus management strategies. Why would that be necessary? We need to reduce the emotional component of tinnitus, and there is a significant association between stress and the severity of tinnitus symptoms. We need to neutralize that component and deactivate the limbic system's fight or flight response. Once we actually reduce that, you will go through the habituation process quite quickly. The limbic activation is what keeps us in the negative cycle and keeps the tinnitus very prominent. If we can reduce your fight or flight stress response, you stop listening to the tinnitus quite quickly, and the habituation process can happen very naturally.

Neutralizing our thoughts and emotions can be a process. It may take some people a period of time, and tinnitus retraining therapy as an approach is generally almost a two-year commitment of working within that process and structure. Richard Tyler, who is an audiologist at the University of Iowa, he likes to classify patients in three categories: those that are curious, those that are concerned, and those that are in crisis. If you are more of a curious level of tinnitus distress, where you may have had tinnitus for many years and you are interested to know what the approaches are, that could potentially offer a little bit of relief, but you're not finding that it is affecting your concentration or your ability to fall asleep, then once you meet for an initial consultation and have your hearing evaluated, you may not require any further services. One session of counseling may be able to relieve the stress and help you to move past the tinnitus symptoms.

Those that are in the concerned category they may have a higher level of bothersome effects where they no longer enjoy quiet activities. Maybe they're starting to remove particular activities that they feel could worsen the symptom from their lifestyle. They're making negative adaptations to the tinnitus experience. Maybe they have trouble falling asleep, and those patients may require a more structured approach with multiple visits. If those attending an appointment are truly in crisis, that would be more of an approach of referring to a mental healthcare provider, because if the anxiety and depression are that significant, following a tinnitus approach would not be the most effective approach, because the tinnitus is not the underlying distress.

Generally, the approach will be a counseling-based approach, but it can be supplemented with the use of sound therapy. What does sound therapy mean? In the experience of tinnitus, generally, your attention will be drawn to the tinnitus because the room is too quiet, so there's too much contrast, and your brain will perceive the tinnitus as the loudest sound because there's nothing to put it into any type of auditory context. Now, counseling can stand by itself; sound therapy is a supplement. Generally, you don't use sound therapy without some measure of counseling, but sound therapy can be more of an immediate relief to patients when it's used because it helps you reduce your awareness of tinnitus. But you have to use it very specifically. You don't want to overwhelm or mask the tinnitus because we can't habituate to an experience if we don't experience it. You have to be able to listen to the tinnitus while simultaneously listening to a therapeutic sound.

Therapeutic sound can be anything that you enjoy. It could be music, it could be nature sounds, it could be broadband noises like fans running, white noise, pink noise, and they're easily obtained through websites and apps and other devices, whatever you would feel comfortable listening to for an extended period of time. Some people like talk radio, so it's truly an individual choice. But that sound that is in use should never be louder than the tinnitus. We want the tinnitus and the sound therapy signal to be at a level where you could direct your attention between both signals.

This is where some people that have done research online will apply sound therapy, but not with the correct guidance. So they're using a very loud level of their sound therapy. That is not going to be effective because again, you don't habituate to something you don't experience. When you turn on your sound therapy, it should be at a very low level that you can hear, but you could also direct your attention back to the tinnitus. Ideally, it should be something that you feel is a pleasant distraction. There are some concerns that using music, because it has an emotional context, could keep you in a more depressed state if the music has emotional content that might be perceived as sad. But certainly, if it's something that you enjoy or gravitate towards, then yes, that is an appropriate use of sound therapy.

When would sound therapy be used? Sound therapy can be used continuously all day to promote a measure of distraction, and I find that it is most effective though when the rooms are very quiet. Let's say you are trying to concentrate on reading an article or doing a task at work. It's good to have your sound therapy playing in the background because it minimizes the contrast of the listening environment so your tinnitus doesn't sound very loud and wouldn't draw your attention. Having something playing lightly in the background is a good choice for a quiet activity.

Let's say it's time for bed and you're getting ready to lie down. Generally, we don't blast loud music when we're trying to fall asleep. So, the room is generally very quiet most of the time. That is when the tinnitus will seem extremely loud. Having a sound generator by the bed or a radio, something that you're using for your sound therapy, play that in order to relax. At that point, you might want to choose a different type of sound therapy. Sound therapy doesn't have to be the same signal all the time. It's there to help you distract and relax, so you can change it in order to meet the needs of the listening environment. At bedtime, maybe you're choosing nature sounds or you're listening to just a white noise to help you drift off to sleep. 

Some people do feel that they hear their tinnitus continuously all day. Listening to your sound therapy for eight hours a day, there's no harm in doing that. Listening to it for eight hours while you're sleeping, no harm in doing that. Some people with sound therapy can have what's called residual inhibition. So even when they take away the sound therapy, they have a measure of being unaware of their tinnitus for an extended period of time.

If you have your hearing evaluated and you actually have an audible hearing loss, then we would approach your sound therapy with the use of amplification. Hearing aids can be an appropriate way of assisting patients with tinnitus because ultimately one theory of tinnitus generation is that the brain is receiving less stimulation because the peripheral sensory organs are no longer functioning optimally, and that is leading to the change in hearing.